When to discontinue anticoagulants (blood thinners) prior to dental surgery?

From the Guidelines

For most dental procedures, anticoagulants should not be stopped, as the risk of thromboembolism from stopping anticoagulation typically outweighs the risk of bleeding during dental procedures, which is usually manageable with local measures. Patients on warfarin can safely undergo dental procedures if their INR is within the therapeutic range (typically 2-3) 1. For patients on direct oral anticoagulants (DOACs) like apixaban, rivaroxaban, dabigatran, or edoxaban, no interruption is typically needed for simple dental procedures, as recommended by the 2018 European Heart Rhythm Association practical guide 1. However, for complex oral surgery, some clinicians may recommend skipping the morning dose on the day of the procedure and resuming the medication that evening or the next day.

Some key points to consider when managing anticoagulation for dental surgery include:

• Local hemostatic measures are usually sufficient to control bleeding, including pressure packs, sutures, tranexamic acid mouthwash (5% solution used as a rinse for 2 minutes, four times daily for 2-5 days), and hemostatic agents like gelatin sponges or oxidized cellulose.
• Patients should inform their dentist about their anticoagulant use before any procedure, and those with additional bleeding risk factors may need individualized management plans developed in consultation with their prescribing physician.
• The timing of the last dose of anticoagulant before surgery can be guided by the half-life of the medication and the patient's renal function, as outlined in studies such as the one published in Blood in 2012 1.
• Postoperative resumption of anticoagulation should be done cautiously, taking into account the patient's individual risk factors and the type of surgery performed.

Overall, the decision to stop or continue anticoagulation for dental surgery should be made on a case-by-case basis, taking into account the patient's individual risk factors and the type of surgery being performed, with the goal of minimizing the risk of both thromboembolism and bleeding complications 1.

From the FDA Drug Label

Apixaban tablets should be discontinued at least 48 hours prior to elective surgery or invasive procedures with a moderate or high risk of unacceptable or clinically significant bleeding [see Warnings and Precautions (5. 2)] . Apixaban tablets should be discontinued at least 24 hours prior to elective surgery or invasive procedures with a low risk of bleeding or where the bleeding would be non-critical in location and easily controlled.

Stopping anticoagulants for dental surgery: The recommended time to discontinue apixaban tablets prior to dental surgery is at least 24 hours for procedures with a low risk of bleeding, and at least 48 hours for procedures with a moderate or high risk of unacceptable or clinically significant bleeding 2.

• Apixaban tablets should be restarted after the surgical or other procedures as soon as adequate hemostasis has been established.

From the Research

Stopping Anticoagulants for Dental Surgery

• The decision to stop anticoagulants for dental surgery should be made on a case-by-case basis, considering the patient's individual risk of bleeding and thrombosis 3, 4, 5.
• Studies have shown that continuing anticoagulation during dental procedures does not increase the risk of bleeding in most cases, and heparin bridging is associated with an increased bleeding incidence 3.
• The use of local hemostatic agents is recommended to manage the risk of bleeding in patients on anticoagulant therapy undergoing dental procedures 3, 4, 5, 6.
• Patients with mechanical heart valves or those at high risk of thrombosis may require anticoagulation therapy, and the decision to stop or continue anticoagulants should be made in consultation with the patient's healthcare provider 7.
• The risk of thromboembolism should be considered when deciding whether to stop anticoagulants, and the duration of subtherapeutic anticoagulation should be minimized to reduce this risk 3, 5.

Management of Anticoagulation Therapy

• Anticoagulation therapy should be managed individually for each patient, taking into account the level of risk of the dental procedure and the risk of thromboembolism 3, 4, 5.
• The use of antifibrinolytic mouthwashes, gelatin sponges, oxidized cellulose, and microcrystalline collagen can be effective in suppressing postoperative bleeding 5.
• Education and collaboration among healthcare professionals are essential for navigating the complexities of anticoagulant therapy and ensuring optimal outcomes for patients 6.

Dental Procedures and Anticoagulation

• Dental procedures with low-to-moderate risk of bleeding can be safely performed in patients on anticoagulant therapy, with careful control of the intensity of anticoagulation and improved methods of local hemostasis 3, 4, 5.
• The management of anticoagulation therapy during dental procedures should be based on the latest evidence and guidelines, and healthcare professionals should stay up-to-date with the latest research and clinical investigations 6.